summary of benefits · pre-enrollment checklist before making an enrollment decision, it is...

2019

Summary of Benefits

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Humana Gold Plus ® SNP-DE H1036-241 (HMO SNP) Daytona Flagler and Volusia counties

Our service area includes the following county/counties in Florida: Flagler, Volusia.

Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-800-833-2364 (TTY: 711) .

Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit Humana.com/medicare or call 1-800-833-2364 (TTY: 711) to view a copy of the EOC.

Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules In addition to your monthly plan premium , you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2020.

Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory).

This plan is a dual eligible special needs plan (D-SNP). Your ability to enroll will be based on verification that you are entitled to both Medicare and medical assistance from a state plan under Medicaid. This plan may enroll dual eligibles who are QMB, SLMB, QI or QDWI.

2019

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Summary of Benefits

Humana Gold Plus ® SNP-DE H1036-241 (HMO SNP)

Daytona Flagler and Volusia counties

Our service area includes the following county/counties in Florida: Flagler, Volusia.

2019 - 5 - Summary of Benefits

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Let’s talk about Humana Gold Plus SNP-DE H1036-241 (HMO SNP) Find out more about the Humana Gold Plus SNP-DE H1036-241 (HMO SNP) plan - including the health and drug services it covers - in this easy-to-use guide. Humana Gold Plus SNP-DE H1036-241 (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the Florida Agency for Health Care Administration (AHCA) Medicaid Program. Enrollment in this Humana plan depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. For a complete list of services we cover, ask us for the “Evidence of Coverage” or you will receive one after you enroll.

As a member you must select an in-network doctor to act as your Primary Care Provider (PCP). Humana Gold Plus SNP-DE H1036-241 (HMO SNP) has a network of doctors, hospitals, pharmacies and other providers. If you use providers who aren’t in our network, the plan may not pay for these services. You have access to Care Managers. Care Managers are nurses or care coordinators who support your health and well-being by providing additional services including: acute and chronic-care management, telephonic and in-person health support; assistance in coordinating Medicare and Medicaid benefits, educational resources and workshops and support for families and caregivers.

To be eligible To enroll in Humana Gold Plus SNP-DE H1036-241 (HMO SNP), a Dual Eligible Special Needs Plan, you must be entitled to Medicare Part A and enrolled in Medicare Part B, live in our service area and also receive certain levels of assistance from the Florida Medical Assistance program (Medicaid). If you receive both Medicare and Medicaid benefits, this means you are a dual eligible. Humana Gold Plus SNP-DE H1036-241 (HMO SNP) may enroll dual eligibles who are QMB, SLMB, QI or QDWI.

Plan name: Humana Gold Plus SNP-DE H1036-241 (HMO SNP)

More about Humana Gold Plus SNP-DE H1036-241 (HMO SNP) Depending on your level of eligibility for assistance under your state Medicaid program, you may or may not be subject to cost-sharing requirements. If you are cost-share protected by the State (QMB or QMB+) you pay nothing. The Comprehensive Benefit Chart shows the benefits you will receive from Humana and how Medicaid covers your cost sharing for those plan benefits if you are in a cost share protected category . The chart also lists some benefits you could receive from Medicaid if you are eligible for full Medicaid benefits. If you are entitled to Medicaid benefits your care coordinator will work with you to assist you in understanding and accessing the Medicare and Medicaid benefits you may be entitled to.

A healthy partnership Get more from your plan — with extra services and resources provided by Humana!

How to reach us: If you have questions about your benefits or your level of eligibility for assistance from Medicaid, you should contact Humana’s Customer Care department or your state Medicaid office for further details. If you’re a member of this plan, call toll-free: 1-800-457-4708 (TTY: 711) .If you’re not a member of this plan, call toll free: 1-800-833-2364 (TTY: 711) .October 1 - March 31: Call 7 days a week from 8 a.m. - 8 p.m. April 1 - September 30: Call Monday - Friday, 8 a.m. - 8 p.m. Or visit our website: Humana.com/medicare .For the most current Florida Medicaid coverage information, please visit the Florida Medicaid website at http://ahca.myflorida.com/ or call the Medicaid Hotline at 1-888-419-3456 (TTY: 711) .

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Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other providers in the network. This is called a “referral.” Certain procedures, services and drugs may need advance approval from your plan. This is called a “prior authorization” or “preauthorization.” Please contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a referral and/or prior authorization from the plan .2019 - 6 - Summary of Benefits

Monthly Premium, Deductible and Limits Monthly plan premium $0 or up to $17.90 depending on your level of assistance

You must keep paying your Medicare Part B premium. The Part B premium may be covered through your State Medicaid Program.

Medical deductible This plan does not have a deductible.

Pharmacy (Part D) deductible $0 or $85 depending on your level of assistance for Tier 2,Tier 3,Tier 4,Tier 5.

Maximum out-of-pocket responsibility

$3,400 in-network

The most you pay for copays, coinsurance and other costs for medical services for the year.

Covered Medical and Hospital Benefits The benefit chart below shows the benefits you will receive as a member of Humana Gold Plus SNP-DE (HMO SNP) (left column) compared to what is currently provided by Traditional Florida Medicaid (right column). If you are currently enrolled in a Medicaid Managed Care Plan, the benefits may be different from what’s listed in the right column. For each benefit listed below, you can see what you pay as a member of our plan compared to Traditional Florida Medicaid’s coverage and charges. NOTE: You cannot be enrolled in both a Medicaid Managed Care plan and a D-SNP plan in Florida. For members protected by the State Medicaid Program from cost sharing, Medicaid pays coinsurance, copays and deductibles for Original Medicare covered services. N/A WHAT YOU PAY ON THIS

HUMANA PLAN COMPARED TO TRADITIONAL FLORIDA MEDICAID BENEFITS (MEDICAID MANAGED CARE PLAN BENEFITS MAY BE DIFFERENT)

ACUTE INPATIENT HOSPITAL CARE N/A $0 or $75 copay per day for days

1-5 $0 copay per day for days 6-90 If you are cost-share protected by the State (QMB) you pay nothing

• $3 copay for each admission*

OUTPATIENT HOSPITAL COVERAGE Outpatient surgery at outpatient hospital

$0 copay N/A

Outpatient surgery at ambulatory surgical center

$0 copay N/A

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Covered Medical and Hospital Benefits (cont.)

N/A WHAT YOU PAY ON THIS HUMANA PLAN

COMPARED TO TRADITIONAL FLORIDA MEDICAID BENEFITS (MEDICAID MANAGED CARE PLAN BENEFITS MAY BE DIFFERENT)

DOCTOR OFFICE VISITS Primary care provider (PCP) $0 copay Specialists $0 copay

• Provider services include physicians, nurse practitioners and physician assistants – $2 copay per provider/group,

per day* • Services provided in federally

qualified health centers (FQHC's), clinics, and rural health centers – $3 copay per clinic, per day*

PREVENTIVE CARE N/A Our plan covers many

preventive services at no cost when you see an in-network provider including: • Abdominal aortic aneurysm

screening • Alcohol misuse counseling • Bone mass measurement • Breast cancer screening

(mammogram) • Cardiovascular disease

(behavioral therapy) • Cardiovascular screenings • Cervical and vaginal cancer

screening • Colorectal cancer screenings

(colonoscopy, fecal occult blood test, flexible sigmoidoscopy)

• Depression screening • Diabetes screenings • HIV screening • Medical nutrition therapy

services • Obesity screening and

counseling • Prostate cancer screenings

(PSA)

N/A

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• Sexually transmitted infections screening and counseling

• Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

• Vaccines, including flu shots, hepatitis B shots, pneumococcal shots

• "Welcome to Medicare" preventive visit (one-time)

• Annual Wellness Visit • Lung cancer screening • Routine physical exam • Medicare diabetes prevention

program Any additional preventive services approved by Medicare during the contract year will be covered.

EMERGENCY CARE Emergency room If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for the emergency care.

$0 or $120 copay If you are cost-share protected by the State (QMB) you pay nothing

Medicaid recipients using the hospital emergency room for non-emergency services are responsible for a 5% coinsurance on the first $300 of the Florida Medicaid payment (maximum $15 ).*

Urgently needed services Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention.

$0 copay at an urgent care center N/A

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DIAGNOSTIC SERVICES, LABS AND IMAGING Diagnostic Mammography $0 copay N/A

Diagnostic radiology $0 copay N/A

Lab services $0 copay N/A

Diagnostic tests and procedures $0 copay N/A

Outpatient X-rays $0 copay N/A

Radiation Therapy $0 copay N/A

HEARING SERVICES Medicare covered hearing $0 copay Routine hearing HER845 • $0 copayment for

fitting/evaluation, routine hearing exam up to 1 per year.

• $1000 maximum benefit coverage amount per ear per year for hearing aids (all types). Note: Includes one month battery supply, 1 year warranty.

• Limited to one evaluation for the purpose of determining hearing aid candidacy, per recipient, every three years from the date of the last evaluation.

• Cochlear implants are limited to one in either ear, but not both and must be prior authorized.

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DENTAL SERVICES The cost-share indicated below is what you pay for the covered service.

Medicare covered dental $0 copay Routine dental DEN137

Use the CAREington Medicare network for the Mandatory Supplemental Dental. The provider locator can be found at Humana.com > Find a Doctor > from the Search Type drop down select Dental > under Coverage Type select All Dental Networks > enter zip code > from the network drop down select CAREington Medicare.

• $0 copayment for scaling and root planing (deep cleaning) up to 1 every 2 years.

• $0 copayment for panoramic film or diagnostic x-rays up to 1 every 3 years.

• $0 copayment for complete dentures, partial dentures up to 1 set(s) every 5 years.

• $0 copayment for bitewing x-rays up to 1 set(s) per year.

• $0 copayment for amalgam or composite filling, crown, denture reline up to 1 per year.

• $0 copayment for periodic oral exam or comprehensive oral evaluation, prophylaxis (cleaning) up to 2 per year.

• $0 copayment for simple or surgical extraction up to 3 per year.

• $0 copayment for necessary anesthesia with covered service up to unlimited per year.

• $0 copay • Limited adult dental services

for recipients ages 21 and over.

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VISION SERVICES Medicare covered vision services

$0 copay

Diabetic eye exam $0 copay Glaucoma screening $0 copay Eyewear (post-cataract) $0 copay Routine vision VIS026

Search for Vision providers in the Medical network of this Medicare Advantage plan.

• $0 copayment for routine exam, refraction up to 1 per year.

• $400 maximum benefit coverage amount per year for contact lenses or eyeglasses - lenses and frames (includes fitting) or 3 pairs of select eyeglasses at no cost.

• Eyeglasses will include ultraviolet protection and scratch resistant coating.

• $2 copay for optometrist services, per provider/group, per day*

• Does not reimburse for screening of visual acuity or for an evaluation and management visit and a general ophthalmologic visit on the same day for the same recipient.

MENTAL HEALTH SERVICES Inpatient Your plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital

$0 or $75 copay per day for days 1-5 $0 copay per day for days 6-90 If you are cost-share protected by the State (QMB) you pay nothing

• $3 copay per admission

Outpatient group and individual therapy visits

$0 copay • $3 copay per outpatient hospital visit

SKILLED NURSING FACILITY (SNF) Your plan covers up to 100 days in a SNF

$0 copay per day for days 1-20 $0 or $95 copay per day for days 21-100 If you are cost-share protected by the State (QMB) you pay nothing

N/A

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PHYSICAL THERAPY $0 copay • Physical therapy services for

recipients under the age of 21 years:

• One initial therapy evaluation per year, per recipient

• One therapy re-evaluation every five months, per recipient

$0 copay AMBULANCE Ambulance (ground) $0 or $200 per date of service

If you are cost-share protected by the State (QMB) you pay nothing

N/A

TRANSPORTATION N/A $0 copay for unlimited trips to

plan approved locations The member must contact transportation vendor to arrange transportation.

$0 copay for emergency transportation

Prescription Drug Benefits WHAT YOU PAY ON THIS HUMANA PLAN


MEDICARE PART B DRUGS Chemotherapy drugs $0 copay N/A

Other part B drugs $0 copay N/A

PRESCRIPTION DRUGS Medicare Part D Drugs See chart below for plan coverage

information for prescription drugs Medicaid may cover some drugs that are not covered by Part D. Contact your Medicaid agency for questions on drug coverage. • $0 copay for Medicaid covered

prescription drugs not covered by a Medicare Prescription Drug Plan.

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Deductible You may pay $0 or $85 depending on your level of Extra Help (only for Tier 2,Tier 3,Tier 4,Tier 5 drugs) . If your deductible is $85, you pay the full cost of these drugs until you reach $85. Then, you only pay your cost-share.

Depending on the level of Extra Help you receive, you'll pay one of the following cost-share amounts each time you fill your drug. You will always pay $0 for Tier 1 drugs on this plan at a Preferred Cost-Sharing Retail or Preferred Cost-Sharing Mail Order Pharmacy.

Pharmacy options Preferred cost-sharing Mail order: Humana Pharmacy ®

Retail: To find the preferred cost-share retail pharmacies near you, go to Humana.com/pharmacyfinder

Standard cost-sharing Mail order: Walmart Mail Retail: All other network retail pharmacies

For generic drugs (including 30-day supply 90-day supply brand drugs treated as generic), either:

$0 copay; or $1.25 copay; or $3.40 copay; or 15% of the cost


For all other drugs , either: $0 copay; or $3.80 copay; or $8.50 copay; or 15% of the cost


Specialty drugs are limited to a 30 day supply.

ADDITIONAL DRUG COVERAGE Erectile dysfunction (ED) drugs This plan also provides coverage for erectile dysfunction drugs. Refer to

your "Evidence of Coverage" for more information.

Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the Part D benefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact the Social Security Office at 1-800-772-1213 Monday — Friday, 7 a.m. — 7 p.m. TTY users should call 1-800-325-0778. For more information on the additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our "Evidence of Coverage" online.

If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy.

You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.

Days' Supply Available Unless otherwise specified, you can get your Part D drug in the following days' supply amounts: • One month supply (up to 30 days)* • Two month supply (31-60 days) • Three month supply (61-90 days)

*Long term care pharmacy (one month supply = 31 days)

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Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,100 , your share of the cost for a covered drug will be either: • $0 or $3.40 for generic (including brand drugs treated as generic) and a $0 or $8.50 copayment for all

other drugs

Additional benefits WHAT YOU PAY ON THIS HUMANA PLAN


Medicare-covered foot care (podiatry)

$0 copay • Podiatrist services $2 copay per provider, per day

Medicare-covered chiropractic services

$0 copay • $1 copay per provider/group, per day

MEDICAL EQUIPMENT/SUPPLIES Durable medical equipment (like wheelchairs or oxygen)

$0 copay $0 copay

Medical Supplies $0 copay Prosthetics (artificial limbs or braces)

$0 copay

Diabetic monitoring supplies $0 copay

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WHAT YOU PAY ON THIS HUMANA PLAN


REHABILITATION SERVICES Physical, occupational and speech therapy

$0 copay

Cardiac rehabilitation $0 copay

• Occupational therapy services • One initial therapy evaluation

per year, per recipient. • One therapy re-evaluation

every five months per recipient • $0 copay • Physical therapy services for

recipients under the age of 21 years:

• One initial therapy evaluation per year, per recipient.

• One therapy re-evaluation every five months per recipient

• $0 copay

Speech-language pathology services for recipients under the age of 21 years: • One initial speech-language

pathology evaluation per year, per recipient

• One speech-language re-evaluation every five months, per recipient

• $0 copay Pulmonary rehabilitation $0 copay N/A

Additional Medicaid Covered Services Dual eligible members who meet financial criteria for full Medicaid coverage may also be eligible to receive all Medicaid services not covered by Medicare. Humana Gold Plus may also offer coverage for these services. The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what the Florida Agency for Health Care Administration (AHCA) Program covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. If you have questions about your Medicaid eligibility and what benefits you are entitled to call: 1-888-419-3456 (TTY: 711).

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BENEFIT WHAT YOU PAY ON THIS HUMANA PLAN

MEDICAID STATE PLAN

PRODUCTS AND DEVICES Dentures See “Dental” benefit in the

“Covered Medical and Hospital Benefits” chart above

• Dentures and related procedures are covered for recipients 21 years of age or older.

• Partial dentures must be prior authorized.

Eyeglasses See “Vision” benefit in the “Covered Medical and Hospital Benefits” chart above

• $0 copay • For person 21 years of age or

older, eyeglass frames are limited to one pair per recipient, every two years, and eyeglass lenses are limited to one pair every 365 days, based on medical necessity. A second set of frames may be dispensed during the two year period with prior approval.

Hearing Aids See “Hearing” benefit in the “Covered Medical and Hospital Benefits” chart above

• $0 copay • Limited to one hearing aid per

ear, per recipient, every three years.

• Does not reimburse for routine maintenance, batteries, cord or wire replacement, or cleaning.

• Does not reimburse for repairs until after the manufacturer’s warranty has expired.

TRANSPORTATION Non-Emergency Medical Transportation Services

See “Transportation” benefit in the “Covered Medical and Hospital Benefits” chart above

• $1 copay per one way trip

INPATIENT LONG TERM CARE SERVICES Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services in Institutions for Mental Diseases (IMD), age 65 and older

Not covered • $0 copay

Inpatient Psychiatric Services, under age 21

Not covered • $0 copay

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Intermediate Care Facility Services for Individuals with Intellectual Disabilities

Not Covered • $0 copay • Limited to fifteen days per

hospital stay • Limited to forty-five days per

Florida fiscal year (July 1 through June 30) for therapeutic leave.

Nursing Facility Services, other than in an Institution for Mental Diseases

Not covered • $0 copay • Limited to eight days per

hospital stay and sixteen days per Florida state fiscal year (July 1 through June 30) for therapeutic home visits.

• Swing bed services cannot exceed 60 days unless a longer stay has been prior authorized.

• Hospital-based skilled nursing unit services cannot exceed 30 days, unless one 15-day extension is prior authorized.

Other Medicaid Covered Services Assistive Care Services Not covered • $0 copay

• Care to eligible recipients living in congregate living facilities and requiring integrated services on a 24-hour per day basis.

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Mental Health Targeted Case Management

Not covered • Limited to adults who have a severe and persistent mental illness and children and adolescents who have a serious emotional disturbance and are in need of service coordination among multiple providers.

• Medicaid will reimburse: Up to 344 units of mental health targeted case management per month, per recipient. Up to 48 units of intensive team services per recipient, per day, per case management team. Fifteen minutes equals one unit of service. If multiple units are provided on the same day, the actual time spent must be totaled and rounded to the nearest fifteen minute increment.

Over-the-Counter (OTC) Benefits See “Over-the-Counter benefits” on the “More benefits with your plan” page

Select over-the-counter items, contained in the Medicaid drug list.

AIDS related Durable Medical Equipment and Medical Supplies

See "Durable medical equipment" benefit in the "Additional benefits" chart above

Specialized medical equipment and supplies (e.g., incontinence supplies) to enrollees with a diagnosis of AIDS, and who have had a history of an AIDS-related opportunistic infection.

AIDS related Therapy Services See "Physical Therapy" benefit in the "Covered Medical and Hospital Benefits" chart above

Medical massage therapy services to enrollees diagnosed with AIDS, and who have had a history of an AIDS-related opportunistic infection for the treatment of peripheral neuropathy or severe neuromuscular pain and lymphedema.

HOME AND COMMUNITY BASED WAIVER SERVICES Dual eligible members, who meet the financial criteria for full Medicaid coverage, may also be eligible to receive Waiver services. Waiver services are limited to individuals who meet additional waiver eligibility criteria. For information on waiver services and eligibility, contact Medicaid at 1-888-419-3456 (TTY: 711).

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*Exemptions. The following categories of recipients are not required to pay a copayment or coinsurance: (a) Individuals under the age of 21 years. (b) Pregnant women – for pregnancy-related services, including services for medical conditions that may complicate the pregnancy. This exemption includes the six week period following the end of the pregnancy. (c) Individuals receiving services in an inpatient hospital setting, long-term care facility, or other medical institution if, as a condition of receiving services in the institution, that individual is required to spend all of his or her income for medical care costs with the exception of the minimal amount required for personal needs. (d) Individuals who require emergency services after the sudden onset of a medical condition which, if left untreated, would place their health in serious jeopardy. (e) Individuals receiving services or supplies related to family planning.

The Additional Medicaid Covered Services table above reflects Medicaid services available on a fee for service basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits.

The Medicaid information included in this section is current as of 7/1/2018. All Medicaid covered services are subject to change at any time. For the most current Florida Medicaid coverage information, please visit the Florida Medicaid website at http://ahca.myflorida.com/ or call the Medicaid Hotline at 1-888-419-3456 (TTY: 711) .


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More benefits with your plan Enjoy some of these extra benefits included in your plan .

Acupuncture $0 copay per visit up to 25 visits every 12 months

Authorization rules apply after 8 visits

Smoking cessation program To further assist in your effort to quit smoking or tobacco product use, we cover one additional counseling quit attempt within a 12-month period as a service with no cost to you. This is in addition to the two counseling attempt provided by Medicare and includes up to four face-to-face visits. This service can be used for either preventive measures or for diagnosis with a tobacco related disease.

Enhanced Nutrition Therapy Additional one-on-one nutrition therapy counseling.

Routine foot care $0 copay per visit for up to 6 visits

Well Dine Meal Program Humana's meal program for members with certain special needs plan (SNP) specific conditions or following an inpatient stay in the hospital or nursing facility

HumanaFirst ® Nurse Hotline Health advice from a registered nurse, available 24 hours a day, seven days a week.

Over-the-Counter (OTC) mail order Up to $100 monthly value for the purchase of OTC supplies from Humana Pharmacy mail delivery.

Virtual Visits – Mental and Behavioral Health Access to doctors and other mental health professionals via phone and/or video technology for diagnosis and treatment of certain non-emergency mental or behavioral issues.

You pay a $0 copay to receive a remote mental and behavioral consultation.

Wigs (related to chemotherapy treatment) Up to an unlimited maximum benefit per year.

Go365 TM by Humana Rewards for completing certain preventive health screenings and health and wellness activities.

SilverSneakers ® fitness program Basic fitness center membership including fitness classes.

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This information is not a complete description of benefits. Call 1-800-457-4708 (TTY: 711) for more information.

To find out more about the coverage and costs of Original Medicare, look in the current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.

This information is available in a different format , including Braille, large print, and audio tapes. Please call Customer Care at the number listed in the beginning of this document if you need plan information in another format. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-833-2364 (TTY: 711).

Humana has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 12/31/2020 based on a review of Humana's Model of Care.

Sponsored by HUMANA MEDICAL PLAN, INC. and the State of Florida, Agency For Health Care Administration.

The provider/pharmacy network may change at any time. You will receive notice when necessary.

Limitations on healthcare and prescription services delivered via virtual visits and communications options vary by state. Virtual visit services are not a substitute for emergency care and not intended to replace your primary care provider or other providers in your network. This material is provided for informational use only and should not be construed as medical advice or used in place of consulting a licensed medical professional.

Humana.com

Find out more

You can see our plan's provider and pharmacy directory at our website at www.humana.com/members/tools or call us at the number listed at the beginning of this booklet and we will send you one.

You can see our plan's drug list at our website at www.humana.com/ medicare/medicare_prescription_drugs/medicare_drug_tools/ medicare_drug_list/ or call us at the number listed at the beginning of this booklet and we will send you one.

Discrimination is Against the Law Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion. Humana Inc. and its subsidiaries do not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion.

Humana Inc. and its subsidiaries provide: (1) free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate; and, (2) free language services to people whose primary language is not English when those services are necessary to provide meaningful access, such as translated documents or oral interpretation.

If you need these services, call 1-877-320-1235 or if you use a TTY , call 711 .If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion, you can file a grievance with Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.

If you need help filing a grievance, call 1-877-320-1235 or if you use a TTY , call 711 . You can also file a civil rights complaint with the U.S. Department of Health and Human Services , Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at U.S. Department of Health and Human Services , 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD) . Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html .

1-877-320-1235 1-877-320-1235

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GCHJV5REN_P 071118

Humana Gold Plus SNP-DE H1036-241 (HMO SNP) H1036241000 ENG Flagler and Volusia counties

Humana.com H1036241000SB19

summary of benefits · pre-enrollment checklist before making an enrollment decision, it is...

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